HomeMy WebLinkAboutPermit Backflow Device 2004-5-26 (2)
225 Fifth Street
Springfield, Oregon 97477
541"-726-3759 Phone
.
.ty of Springfield Official Receipt
velopment Services Department
Public Works Department
RECEIPT #:
1200400000000000807
Date: OS/26/2004
11:01:31AM
Job/Journal Number
COM2004-00623
COM2004-00623
COM2004-00623
COM2004-00623
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Backflow Device
Minimum/Adjustment Plumbing
Payments:
Type of Payment Paid By
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
Amount Due
3.15
4.50
14.00
31.00
$52.65
Amount Paid
Check
REXIUS
djb
54442
In Person
Payment Total:
$52.65
$52.65
5/26/2004
Page 1.0f I
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CITY OF SPRINGFIELD
Status
Issued
Building/Combination Permit
PERMIT NO: COM2004-00623
ISSUED: OS/26/2004
APPLIED: OS/26/2004
EXPIRES: 11/26/2004
VALUE:
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
I Fees paiiJ
Fee Description
+ 10% Administrative Fee
+ 7% State Surcharge
Backflow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
$4.50
$3.15
$14.00
$31.00
5/26/04
5/26/04
5/26/04
5/26/04
Receipt Number
1200400000000000807
1200400000000000807
1200400000000000807
1200400000000000807
Total Amount Paid
$52.65
Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. All inspection requested before 7:00 a.m.
will be made the same working day, inspections requested after 7:00 a.m. will be made the following work
day.
I Reouired InVlections I
1 Backflow Device: Prior to covering and provide a copy of the test report on site at the time of inspection.
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springfield and the Laws of the State of Oregon pertaining to the work described herein, and
that NO OCCUPANCY will be made ofany structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project.
I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the
street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all
times durin constru ti
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F;;2-1o -t7 Y
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Owner or Contractors Signature
Date
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